Psychological Assessment

2003, Vol. 15, No. 4, 569 577

Copyright 2003 by the American Psychological Association, Inc.

1040-3590/03/$12.00 DOI: 10.1037/1040-3590.15.4.569

Psychometric Properties of the Spanish Beck Depression InventoryII

in a Medical Sample
Julie A. Penley

John S. Wiebe

El Paso Community College

University of Texas at El Paso

Azikiwe Nwosu
Texas Tech University Health Sciences Center

The authors examined the psychometric properties of the Spanish Beck Depression InventoryII (BDI-II;
A. T. Beck, R. A. Steer, & G. K. Brown, 1996) in a sample of individuals undergoing hemodialysis. They
performed a confirmatory factor analysis of a previously reported 2-factor solution for the English BDI-II
derived from a medical sample. Results indicate that the established model for the English-speaking
medical sample provided adequate fit in the present sample. Spanish BDI-II scores were not significantly
associated with age or gender in their sample, but they were significantly associated with disease severity.
Bilingual participants completed the inventory in both Spanish and English, and their data revealed that
BDI-II total scores were similar across language administration. The preliminary data suggest that the
Spanish BDI-II can be reliably used in medical samples.

or one of its revisions (BDI-I; Beck, Rush, Shaw, & Emery, 1979;
BDI-IA; Beck & Steer, 1993b). However, a major shortcoming of
each instrument has been its limited content validity in light of
current criteria for diagnosing depression. As a result, Beck and his
colleagues modified the BDI-IA to more accurately reflect the
diagnostic criteria for major depressive disorders (MDD) presented in the American Psychiatric Associations Diagnostic and
Statistical Manual of Mental Disorders (4th ed.; DSMIV; 1994).
In developing the BDI-II (Beck et al., 1996), the authors removed
the weight loss, body image disturbance, somatic preoccupation,
and work difficulty items, and added items tapping agitation,
worthlessness, concentration difficulty, and loss of energy. Another important change is that the authors extended the point of
reference in the BDI-II from 1 to 2 weeks, which corresponds to
the DSMIV criteria for MDD.

We examined the reliability and validity of scores from the

Spanish translation of the Beck Depression InventoryII (BDI-II;
Beck, Steer, & Brown, 1996), administered to a medical sample.
The BDI-II is a relatively new instrument, which Beck et al. (1996)
described as a substantial revision of its predecessor, the Beck
Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, &
Erbaugh, 1961). Although psychometric data for the English
BDI-II have begun to emerge, there are currently no published data
for the Spanish BDI-II.

BDI-II
To date, one of the most frequently used self-report measures of
depressive symptomatology has been the BDI (Beck et al., 1961)
Julie A. Penley, Department of Psychology, El Paso Community College; John S. Wiebe, Department of Psychology, University of Texas at El
Paso; Azikiwe Nwosu, Department of Internal Medicine, Texas Tech
University Health Sciences Center.
The present data are part of Julie A. Penleys doctoral dissertation
submitted to the University of Texas at El Pasos Department of Psychology, in which John S. Wiebe was the chairperson and Azikiwe Nwosu was
a committee member. Portions of this article were presented at the March
2002 Annual Meeting of the Society of Behavioral Medicine in Washington, DC. We thank the patients and staff of Loma Vista Dialysis Center and
Mesa Vista Dialysis Center for their participation and assistance with this
study and Lori Garcia and Jerry Avila for providing the patient severity
ratings. In addition, we are grateful to Jessica Calderon, Grecia Garca,
Dolores Hernandez, Aracely Ibarra, Ernesto Marn, and Virginia Zuverza
for their invaluable assistance with data collection and data coding. Finally,
we thank The Psychological Corporation for allowing us to use the Beck
Depression InventoryII free of charge in this research.
Correspondence concerning this research should be addressed to Julie
A. Penley, Department of Psychology, El Paso Community College, P.O.
Box 20500, El Paso, Texas 79998-0500. E-mail: juliep@epcc.edu

Psychometric Properties of the BDI-II

Psychometric data for the English-language BDI-II have only
begun to emerge. Among student samples, internal reliability of
BDI-II scores has ranged from .89 (Steer & Clark, 1997;
Whisman, Perez, & Ramel, 2000) to .93 (Beck et al., 1996).
Among psychiatric samples, the internal reliability has ranged
from .89 (Steer, Rissmiller, & Beck, 2000) to .92 (Beck
et al., 1996). In one of the few published studies using a medical
sample, Arnau, Meagher, Norris, and Bramson (2001) reported an
internal reliability of .94.
The BDI-II has demonstrated convergent and discriminant validity, with BDI-II scores correlating more strongly with the Hamilton Rating Scale for Depression (Hamilton, 1960) than with
either the Hamilton Rating Scale for Anxiety (Hamilton, 1959) or
the Beck Anxiety Inventory (Beck & Steer, 1993a). The BDI-II
has also evidenced further criterion-related validity, with partici569

570

PENLEY, WIEBE, AND NWOSU

pants diagnosed with MDD scoring significantly higher on the

BDI-II than participants not diagnosed with MDD (Arnau et al.,
2001).
As with earlier versions of the BDI, researchers have found the
BDI-II to contain two first-order factors of depression and a single
second-order factor of depression (Arnau et al., 2001; Steer, Ball,
Ranieri, & Beck, 1999). Beck et al. (1996) have labeled the
first-order factors SomaticAffective Depression (e.g., Fatigue,
Loss of Energy, Crying) and Cognitive Depression (e.g., Pessimism, Worthlessness). However, researchers have not consistently
replicated Beck et al.s factors, nor have they used Beck et al.s
labels. The variations in factor loadings and labels are not surprising given the different types of samples (i.e., medical vs. student
vs. clinical) and are in fact consistent with Beck and Steers
(1993b) note that the BDI factor structure changes as a function of
sample characteristics as well as with which extraction method the
researcher used. However, given that the present study examines
the Spanish BDI-II in a medical sample, we were specifically
interested in the structure of the English BDI-II in this population.
To date, Arnau et al. (2001) have presented the only known data
from such a sample. They report two first-order factors for the
BDI-II: Their first factor, SomaticAffective, includes 12 items
(i.e., sadness, loss of pleasure, agitation, loss of interest, indecisiveness, loss of energy, changes in sleeping patterns, irritability,
changes in appetite, concentration difficulty, tiredness/fatigue, and
loss of interest in sex). Their second factor, Cognitive, includes 8
items (pessimism, past failure, guilty feelings, punishment feelings, self-dislike, suicidal thoughts/wishes, crying, and worthlessness). The authors reported that 1 item, self-criticalness, did not
load saliently on either factor. Arnau and his colleagues also
reported one second-order general depression factor, which accounted for most of the variance in the two first-order factors.
Also consistent with previous versions of the BDI are researchers mixed findings for demographic correlates of BDI-II scores.
For example, some studies have found that womens BDI-II scores
are significantly higher than are mens scores (Arnau et al., 2001;
Beck et al., 1996), but other studies have found no significant
gender differences (Dozois, Dobson, & Ahnberg, 1998; Steer et
al., 2000). Similarly, some studies have found that BDI-II scores
are not significantly correlated with age (Beck et al., 1996, Steer et
al., 2000), whereas Steer et al. (1999) reported an inverse association with age.
Researchers have not found significant differences in BDI-II
scores between ethnic groups (Beck et al., 1996; Steer et al., 2000).
However, there are no published studies to date that have examined the association between BDI-II scores and acculturation, or
the affective, cognitive, and behavioral changes that result from
exposure to or contact with another culture (Berry, 1980; Gordon,
1964). Several researchers have reported an inverse correlation
between acculturation and other measures of depression (Damji,
Clement, & Noels, 1996; Miranda & Umhoefer, 1998; Zamanian
et al., 1992). One limitation of many studies that have found a
negative correlation between acculturation and depression, however, is that the researchers did not control for the correlation
between depression and socioeconomic status (SES), a factor that
is correlated with both acculturation (Cuellar & Roberts, 1997;
Negy & Woods, 1992) and depression (Sykes, Hanley, Boyle,
Higginson, & Wilson, 1999; Turner, Lloyd, & Roszell, 1999). The
two variables often used to measure SES are education and income

(e.g., Hollingshead, 1975), and indeed, there is some evidence that

BDI-II scores are negatively correlated with both of these variables
(Arnau et al., 2001).
In general, results to date have suggested that the BDI-II produces reliable and valid scores in English-speaking samples. However, there is no published evidence concerning the psychometric
properties of other-language translations of the inventory. The
purpose of the present research is to examine the reliability of
scores from the Spanish translation of the BDI-II. A second purpose is to examine the adequacy of the English inventorys twofactor structure, derived from a medical sample, in a Spanishspeaking medical sample.

Spanish BDI-II
A group of psychologists from the United States, Mexico,
Central and South America, Cuba, and Puerto Rico translated the
BDI-II into Spanish. The translators used the back-translation
technique (Brislin, Lonner, & Thorndike, 1973), subjecting the
inventory to multiple rounds of translations to eliminate cultural
influences that may bias individuals responses (J. Trent, personal
communication, September 12, 2001). Regrettably, the Spanish
translation was not pilot tested, and there have been no data
collected speaking to the comparability of the translation to the
English BDI-II.
The Spanish translation of the BDI-II is an important version to
examine, as Spanish is the second most commonly used language
in the United States after English. Data from the 1990 United
States Census revealed that over 17.3 million people in the United
States spoke Spanish at home. At the time, this number represented
less than 8% of the total U.S. population (United States Census
Bureau, 1990). According to the 2000 U.S. Census, the number of
people who speak Spanish at home has risen to over 28.1 million,
or approximately 10.7% of the total United States population
(United States Census Bureau, 2000). Of the 28.1 million Spanish
speakers, almost 30% (approximately 7.9 million) reported speaking English not well or not at all. The substantial increase in
the number of people who speak Spanish at home, combined with
the number that report not speaking English well, presents a
challenge for researchers and clinicians who need to assess depressive symptomatology among their participants or patients.
There is clearly a need for reliable Spanish translations of questionnaires used in research and clinical settings, such as the BDI-II.

Illness Context
The present study was carried out with a sample of primarily
Mexican American patients receiving hemodialysis as a treatment
for end-stage renal disease (ESRD). ESRD is a chronic illness that
is inevitably fatal unless managed through complex medical intervention and patient adherence to a demanding regimen of medication and dietary and fluid restrictions. Nearly half a million
patients in the United States suffer from the disorder, which cuts
across all ages, ethnic groups, and socioeconomic strata ( United
States Renal Data System, 2001). Epidemiological studies have
shown that Mexican and Mexican American individuals suffer a
much greater incidence of ESRD than do non-Hispanic Whites
(Pugh, Stern, Haffner, Eifler, & Zapata, 1988; Rostand, 1992). It
was important to examine this sample because researchers have

SPANISH BDI-II

found that patients with chronic medical conditions or diseases

often report higher levels of depression than does the general
population. Researchers have found higher levels of self-reported
depression not only in ESRD (e.g., Binik, Devins, & Orme, 1989;
Hinrichsen, Lieberman, Pollack, & Steinberg, 1989; Kutner, Brogan, Hall, Haber, & Daniels, 2000) but also in a variety of other
medical samples, including patients with chronic fatigue syndrome
(Buckley et al., 1999), coronary artery disease (Barefoot et al.,
2000), and cancer (Carroll, Kathol, Noyes, Wald, & Clamson,
1993).
In addition, several researchers have found a positive association between depression and disease severity in medical samples
(e.g., Ciaramella & Poli, 2001; Kutner et al., 2000; Schaeffer et al.,
1999). The increased prevalence of depression in medical samples,
in turn, has important implications for disease treatments and
outcomes. Specifically, researchers have reported negative associations between depression and adherence to medical regimens
(Gordillo, del Amo, Soriano, & Gonzalez-Lahoz, 1999; Mohr et
al., 1997) and positive associations between depression and mortality in ESRD (Burton, Kline, Lindsay, & Heidenheim, 1986) and
other chronic illnesses (e.g., Barefoot et al., 2000; Ickovics et al.,
2001).

Overview and Hypotheses

Scores from the English-language BDI-II have demonstrated
reliability and validity in psychiatric, medical, and student samples. Furthermore, researchers have consistently found that the
English BDI-II contains two first-order factors (which Arnau et al.,
2001, labeled SomaticAffective and Cognitive) and a single
second-order factor of depression. However, there are currently no
data that address the Spanish translation of the BDI-II. The present
research documented the reliability of scores from the Spanish
BDI-II in a medical sample and examined the adequacy of Arnau
et al.s (2001) reported factor structure in a Spanish-speaking
medical sample.
Consistent with findings from the English BDI-II, we hypothesized that the Spanish BDI-II would be negatively associated with
acculturation, but that the association would be largely attributable
to SES and its association with both acculturation and BDI-II
scores. We also hypothesized that disease severity would be positively correlated with BDI-II scores.

Method
Participants
Hemodialysis patients at two dialysis centers in El Paso, Texas, were
invited to participate in the present study. Of the 177 patients approached,
165 (93.2%) initially agreed to participate. Of these patients, 23 (13.9%)
could only participate in English, and 20 (12.1%) failed to complete the
Spanish BDI-II. These 43 patients were excluded from subsequent analyses, producing a final sample of 122 patients (68.9% of those originally
approached).
The sample consisted of 72 men and 50 women (59% and 41% of the
sample, respectively). A majority of participants were Hispanic (n 120)
and reported being either Catholic (n 92) or Protestant (n 21).
Participants reported being married (n 74), widowed (n 20), or
separated or divorced (n 20). The mean age in the present sample was
62.5 years, with a range of 24 88 years. At the time of participation,

571

patients had been on dialysis for an average of 35.9 months (range: 1167,
Mdn 27.4 months).

Materials
Demographics. Demographic data included individuals date of birth,
gender, marital status, ethnicity, employment status, education, religious
affiliation, when they were diagnosed as having kidney failure, and when
they began dialysis. Two certified translators translated the demographic
questionnaire into Spanish using the back-translation technique (Brislin et
al., 1973). Specifically, the first translator translated the original English
language questionnaire into Spanish; the second translator then independently translated the Spanish translation of the questionnaire back into
English. Differences between the original English version and the backtranslated English version were resolved in a meeting with the translators
and three other individuals: (a) John S. Wiebe; (b) the Coordinator of the
University of Texas at El Pasos Translation and Interpretation Program, a
doctoral-level faculty member who is fluent in Spanish and English; and
(c) Julie A. Penley.
SES. Hollingsheads (1975) Two-Factor Index of Social Position was
used to calculate patients SES. Total SES scores can range from 8 to 66,
with larger values indicating higher SES. Consistent with Hollingsheads
guidelines, two trained individuals computed SES scores by scaling participants self-reported education and employment status, multiplying each
by the designated factor weight (i.e., 3 and 5, respectively), and summing
the two weighted values. The raters for the present sample achieved an
agreement of r .98. SES scores in the present sample ranged from 8 to
66, with a mean score of 21.58 (SD 13.74). The median score was 18,
corresponding to a status of unskilled laborer.
Acculturation. Acculturation was assessed with the Short Acculturation Scale (SAS; Marn, Sabogal, Marn, Otero-Sabogal, & Perez-Stable,
1987). The scale contains 12 items tapping three aspects of acculturation
from Hispanic to Anglo culture: language use (e.g., What language(s) do
you usually speak at home?), media preferences (e.g., In what language(s) are the TV programs you usually watch?), and ethnic social
relations (e.g., Your close friends are. . . ). Marn et al. (1987) created
items for the SAS questionnaire either in English or in Spanish, translating
each item into the other language using the back-translation technique
described previously. The authors then pretested the English and the
Spanish versions of the SAS; in addition, Spanish speakers of different
nationalities reviewed the Spanish version to eliminate regional phrasing.
The authors found that the items have similar factor structures in both
Hispanic and non-Hispanic samples, providing evidence for the measures
applicability in the two ethnic groups.
In their original sample, Marn et al. (1987) found that the SAS items
demonstrated an internal reliability of .92; in the present sample,
internal reliability for the 12 items was .94. Items are rated along a
5-point scale, ranging from 1 (only Spanish/all Hispanics) to 5 (only
English/all Anglos). Summing the 12 items produces a total acculturation
score, ranging from 12 to 60, with higher scores indicating higher levels of
acculturation to Anglo culture. Scores in the present sample ranged from 12
to 51, with a mean of 21.71 (SD 9.36) and a median of 18. On average,
the sample evidenced low to moderate levels of acculturation to Anglo
culture.
Depression. Depressive symptomatology was assessed with the Spanish BDI-II (Beck et al. 1996). Item responses are summed to yield a total
score, ranging from 0 to 63, with higher scores suggesting increased
depressive symptomatology.
Disease severity. Severity of participants renal disease was assessed
with the End-Stage Renal Disease Severity Index (ESRD-SI; Craven,
Littlefield, Rodin, & Murray, 1991). The ESRD-SI measures 10 disease
categories that are often concerns for hemodialysis and other ESRD patients (e.g., peripheral vascular disease, diabetes mellitus, bone disease) as
well as an other category for diseases not otherwise specified. Categories
are individually weighted for severity on the basis of established criteria

PENLEY, WIEBE, AND NWOSU

572

(see Craven et al., 1991), and items are summed to yield a total severity
score. Scores can range from 0 to 93, with higher scores suggesting greater
disease severity.
In samples of both in-center and home hemodialysis patients, Craven et
al. (1991) reported high interrater reliability (r .92) and high 1-week
testretest reliability (r .92). Criterion validity has been demonstrated by
the association of ESRD-SI scores with functional impairment, patient age,
disability unemployment status, the presence of diabetes mellitus, and
death within 6 months of rating (Craven et al., 1991). In a mixed sample
of in-center and peritoneal dialysis patients, Griffin, Friend, and Wadhwa
(1995) found links between ESRD-SI scores and physiological indices of
severity (i.e., serum creatinine and serum albumin levels) and physicians
ratings of functional status.
For each patient who participated in the present study, direct-care
nursing staff rated each disease category as either present (along a 5-point
severity scale) or absent. ESRD-SI scores in the present sample ranged
from 1 to 72, with a mean of 31.65 (SD 16.50) and a median of 30. On
average, then, the samples disease severity would be categorized as mild
to moderate (see Craven et al., 1991).

Procedure
Research assistants approached patients at the dialysis centers to explain
the purpose of the study and to seek their consent to participate. The
research assistants invited patients to participate in a quality-of-life study
of individuals undergoing hemodialysis. Potential participants were told
that the research focused on how individuals with kidney disease adapt
over time to the demands of their medical treatment and, specifically, on
how they had been feeling lately. The assistants also told individuals who
agreed to participate that their medical charts would be reviewed and that
the nursing staff would assess their current health status. Participants were
assured that all of their information would remain confidential, and they
were given contact information for Julie A. Penley and John S. Wiebe if
they had any questions. Assistants approached patients individually, presenting all information and questionnaires in either Spanish or English on
the basis of the patients language abilities and preferences.
If patients understood both English and Spanish, assistants asked them to
complete the BDI-II in their second (i.e., nondominant) language first,
followed by their dominant language. Of the 122 participants, 23 could
complete the BDI-II in both languages; 21 of the 23 bilingual participants
completed the English BDI-II first, and two of the 23 bilingual participants
completed the Spanish BDI-II first. Patients received $10 for participating
in this study.

Results

Table 1
Spanish Beck Depression InventoryII Item Means, Standard
Deviations, Percentage Symptomatic, and Corrected Item-Total
Correlations (N 122)
Symptom

SD

rtot

Sadness
Pessimism
Past failure
Loss of pleasure
Guilty feelings
Punishment feelings
Self-dislike
Self-criticalness
Suicidal thoughts or wishes
Crying
Agitation
Loss of interest
Indecisiveness
Worthlessness
Loss of energy
Changes in sleeping patterns
Irritability
Changes in appetite
Concentration difficulty
Tiredness or fatigue
Loss of interest in sex

0.48
0.69
0.42
1.07
0.47
0.59
0.47
0.60
0.19
0.70
0.64
0.73
0.65
0.77
1.27
1.02
0.59
0.83
0.68
1.33
1.29

0.79
1.04
0.90
1.07
0.82
1.03
0.87
0.98
0.50
1.01
0.95
1.04
0.98
0.94
1.00
1.03
0.89
0.85
0.90
1.08
1.26

32.8
38.5
21.3
63.1
31.1
31.1
26.2
33.6
14.8
39.3
41.0
41.0
37.7
50.8
74.6
59.8
38.5
58.2
44.3
73.8
60.7

.58
.68
.71
.64
.53
.52
.65
.55
.33
.58
.47
.68
.63
.72
.60
.41
.54
.45
.66
.63
.45

Note. % Percentage endorsing nonzero response options. rtot corrected item-total correlations. Item scores could range from 0 to 3, with
higher scores suggesting greater symptomatology.

after we made a Bonferroni adjustment for familywise error rates.

Corrected item-total correlations ranged from 0.33 (suicidal
thoughts or wishes) to 0.72 (worthlessness). It should be noted that
each of the 21 Spanish BDI-II items evidenced a positively skewed
distribution in the present sample. As such, square-root transformations were performed to overcome the difficulties associated
with nonnormal distributions and to permit exploration of the
factorial structure of the data (see Tabachnick & Fidell, 1989).
Table 2 presents the intercorrelations among the 21 transformed
Spanish BDI-II items. Correlations ranged from .12 (loss of
interest in sex and suicidal thoughts or wishes) to .63 (loss of
interest and worthlessness).

Internal Consistency of the Spanish BDI-II

Factorial Structure of the Spanish BDI-II

The Spanish BDI-II scores evidenced good internal consistency

in the sample ( .92). Spanish BDI-II total scores ranged from
0 to 52, with a mean of 15 (SD 12.50) and a median of 12.50.
Using Beck et al.s (1996) criteria, we found that the sample on
average could have been described as minimally to mildly depressed. Specifically, 66 patients (54.1%) were categorized as
minimally depressed, 23 (18.9%) as mildly depressed, 17 (13.9%)
as moderately depressed, and 16 (13.1%) as severely depressed.
Table 1 presents the means and standard deviations for the
Spanish BDI-II in our sample. Item means ranged from 0.19
(suicidal thoughts or wishes) to 1.33 (tiredness or fatigue). Table 1
also presents the percentage of patients who endorsed the item
(i.e., percentage giving a nonzero response) and the corrected
item-total correlations for each item. All of the corrected item-total
correlations were significant ( p .05) and remained significant

To test the adequacy of the BDI-II factor structure found in

Arnau et al.s (2001) medical sample, we performed a confirmatory factor analysis (CFA) on the transformed Spanish BDI-II data
using structural equation modeling (SEM) software (EQS 5.7b;
Bentler, 1998). Kline (1998) advises researchers to examine multiple indices of model fit when interpreting SEM results, as any
one index of fit necessarily emphasizes certain aspects of the
model. Although SEM programs such as EQS return several fit
indices, Kline recommended reporting (a) an index of the variance
that is accounted for by the model, such as Bentlers comparative
fit index (CFI), (b) an index that adjusts (for model complexity) the
variance accounted for in the model, such as BentlerBonetts
nonnormed fit index (NNFI; Bentler & Bonett, 1980), and (c) an
index of the standardized residuals from the model, such as the
root-mean-square residual (RMSR). Kline also recommended re-

p .01.

1
c

.53

2
c

.55
.51c

p .001. All tests are 1-tailed.

Sadness
Pessimism
Past failure
Loss of pleasure
Guilty feelings
Punishment feelings
Self-dislike
Self-criticalness
Suicidal thoughts/wishes
Crying
Agitation
Loss of interest
Indecisiveness
Worthlessness
Loss of energy
Changes in sleeping patterns
Irritability
Changes in appetite
Concentration difficulty
Tiredness or fatigue
Loss of interest in sex

p .05.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.

Questionnaire item
c

.31
.53c
.35c

4
c

.33
.34c
.43c
.35c

5
b

.24
.35c
.44c
.31c
.49c

6
c

.43
.56c
.62c
.38c
.37c
.46c

7
c

.31
.40c
.56c
.42c
.47c
.40c
.52c

Table 2
Intercorrelations Among Spanish Beck Depression InventoryII Items (N 122)

.19
.16a
.25b
.05
.20a
.25b
.29b
.27b

9
.57
.42c
.48c
.36c
.28b
.28b
.36c
.44c
.34c

10
.37
.41c
.33c
.28b
.34c
.32c
.29b
.19a
.13
.30c

11
.31
.57c
.43c
.51c
.28b
.37c
.43c
.38c
.11
.16a
.28b

12
.35
.49c
.45c
.35c
.41c
.36c
.44c
.41c
.26b
.42c
.38c
.49c

13
.35
.53c
.50c
.38c
.32c
.40c
.42c
.33c
.27b
.28b
.25b
.63c
.52c

14
.28
.30c
.37c
.41c
.23b
.15
.30c
.30c
.05
.32c
.06
.41c
.25b
.40c

15
.19
.20a
.16a
.34c
.03
.12
.20a
.30c
.11
.25b
.16a
.31c
.08
.29b
.46c

16

.22
.50c
.31c
.25b
.12
.17a
.34c
.23b
.18a
.19a
.32c
.49c
.31c
.43c
.30c
.35c

17

.22
.22b
.23b
.31c
.14
.12
.13
.07
.13
.34c
.25b
.29b
.31c
.32c
.31c
.25b
.28b

18

.36
.37c
.46c
.37c
.23b
.33c
.35c
.31c
.21a
.48c
.29b
.36c
.51c
.35c
.32c
.31c
.26b
.37c

19

.26
.37c
.34c
.35c
.31c
.34c
.21a
.29b
.16a
.32c
.20a
.42c
.31c
.43c
.61c
.40c
.32c
.40c
.47c

20

.19a
.21a
.24b
.38c
.27b
.17a
.15
.26b
.12
.29b
.24b
.31c
.34c
.23b
.46c
.21b
.19a
.36c
.43c
.46c

21

SPANISH BDI-II

573

574

PENLEY, WIEBE, AND NWOSU

porting the value for a chi-square and its associated degrees of

freedom, which tests whether the model is significantly worse than
a just-identified model (i.e., a model in which the number of
parameters equals the number of observations). However, because
the chi-square statistic is sensitive to sample size and often returns
significant results in even modest samples, he suggested computing and reporting a chi-square as a ratio to its degrees of freedom.
Using the above indices, one finds that good models would
typically have (a) initial- and adjusted-fit indices greater than .90,
(b) RMSR values less than .10, and (c) a chi-square to degree of
freedom ratio of less than 3.00 (Kline, 1998).
The CFI in the present model was .76; NNFI .76, RMSR
.04, and root-mean-square error of approximation (RMSEA) .10
(90% confidence interval [CI] 0.08 to 0.11). Finally, 2(207, N
122) 443.20, 2/df 2.14. The model could therefore be
labeled good on the basis of the 2/df value and on the model
error indices (i.e., RMSR and RMSEA). The small CI for RMSEA
was also encouraging and suggested that the model fit in the
population could be reliably estimated. However, the model was
less than good based on the two fit indices and the overall chisquare statistic. Taken together, then, the SEM results preclude
definitively labeling Arnau et al.s model as good in the present
sample but do suggest that this model provides an adequate fit to
the present Spanish BDI-II patient data.1

Demographic Correlates of the Spanish BDI-II

Age was not significantly correlated with Spanish BDI-II total
scores in the current sample (r .11). Similarly, although
women demonstrated somewhat higher BDI-II mean total and
scale scores, gender was not reliably associated with BDI-II total
score or with the two scale scores in the present sample, all
ts(120) 1.62, all ps .05. In contrast, Spanish BDI-II total
scores were significantly associated with disease severity, r .22,
p .05, one-tailed. Follow-up and exploratory analyses revealed
that the significant association was present in both the Cognitive
and SomaticAffective Scale scores (rs .19 and .23, respectively, ps .05).2 In other words, patients with higher ESRD-SI
scores reported significantly higher levels of both cognitive and
somaticaffective symptoms of depression compared with patients
with lower ESRD-SI scores.
Finally, acculturation was significantly associated with Spanish
BDI-II total scores (r .23, p .05). However, SES was
equally effective in predicting BDI-II scores (r .28, p .05).
In fact, there was no significant unique effect for acculturation on
scores from the BDI-II after the effect of SES was partialed out
(r .14, ns).

Comparisons of Spanish and English BDI-II Data

Because there are currently no data on the equivalence of the
Spanish and English BDI-II, we analyzed the data from the patients who completed the BDI-II in both Spanish and English.
Given the limited statistical power associated with the small sample size (23), we emphasize that these analyses were purely exploratory, and their results should be interpreted tentatively. The
only a priori hypothesis was that the Spanish and English scores
would be positively correlated.

The correlation between participants Spanish and English

BDI-II total scores was statistically significant (r .70, p .05),
and there was no statistically significant difference between Spanish and English BDI-II total scores (M 12.13 vs. 14.74, respectively; paired t(22) 1.44, ns). Using Beck et al.s (1996)
scoring guidelines, we categorized the subsample as minimally
depressed on the basis of the average Spanish BDI-II total score
but as mildly depressed on the basis of the average English BDI-II
total score. Using the Spanish scores, we categorized 15 patients
(65.2%) as minimally depressed, 5 (21.7%) as mildly depressed, 0
as moderately depressed, and 3 (13.0%) as severely depressed.
Using the English scores, however, we found the numbers and
percentages in each depressive category were 11 (47%), 7 (30.4%),
2 (8.7%), and 3 (13.0%), respectively.
Interestingly, although 3 patients were categorized as severely
depressed in both Spanish and English, only 1 patient was categorized in both measures. In fact, 7 patients (30.4% of the bilingual
subsample) were placed into different depressive categories depending on whether their Spanish or English scores were considered. Five of the 7 patients were placed into more severe depressive categories on the basis of their English BDI-II total score, and
2 were placed into more severe depressive categories on the basis
of their Spanish BDI-II total score. Of the 7 patients placed into
different depressive categories, 4 were placed into a nonadjacent
depressive category (e.g., Spanish: mildly depressed; English:
severely depressed).

Discussion
We examined the reliability and factor structure of Spanish
BDI-II scores in a sample of hemodialysis patients. The internal
reliability of the Spanish BDI-II scores is comparable to that from
samples using the English BDI-II (range: .89 to .94), suggesting
that items from the Spanish instrument are addressing a unitary
construct in this sample. The range of the corrected item-total
correlations in the present sample also compares favorably to the
English BDI-II in both student and psychiatric samples (Dozois et
al., 1998; Steer & Clark, 1997; Whisman et al., 2000), although the
present range is somewhat larger than those in the Englishlanguage medical sample (range: .54 to .74; Arnau et al., 2001).
Our CFA of a previously reported factor structure found in a
medical sample suggested an adequate fit of the model that depicted two first-order depression factors and one second-order or
general depression factor. The presence of a general factor in the
present sample also provides some evidence of the Spanish BDIIIs construct validity by confirming the existence of a single
Depression construct that, in turn, can be separated into the two
specific constructs of Cognitive Depression and Somatic
Affective Depression (see Arnau et al., 2001).
1
At the request of an anonymous reviewer, we also performed a CFA of
Arnau et al.s (2001) model using the raw scores from the present sample.
Using the raw scores did not noticeably affect the variance accounted for
in the model, but they did increase the amount of error in the model, CFI
.75, NNFI .75, RMSR .12, RMSEA .11, 2(207, N 122)
483.20, 2/df 2.33.
2
Scale scores are based on Arnau et al.s (2001) factor structures (see
p. 5).

SPANISH BDI-II

The negative correlation between SES and BDI-II scores in our

sample is consistent with previous research (Arnau et al., 2001;
Sykes et al., 1999). In addition, the negative association between
acculturation and depression in the present sample finds support in
the literature (Miranda & Umhoefer, 1998; Mirowsky & Ross,
1984). However, in our data, the effect for acculturation was
nonsignificant after controlling for SES. Although further research
into the role of SES is needed, our findings suggest that researchers
consider including specific aspects of acculturation when exploring the role of the larger acculturation construct.
Finally, the hypothesis of a positive correlation between disease
severity and Spanish BDI-II scores is supported in the present
sample. The association is consistent with Arnau et al.s (2001)
results and with previous research indicating a positive association
between disease severity and depression (Ciaramella & Poli, 2001;
Schaeffer et al., 1999). This finding may raise questions about the
validity of using the somatic depression factor in a chronically ill
population such as the present hemodialysis sample. Indeed, previous researchers concerned about this issue have examined this
possibility by deleting the BDI items that reflect somatic symptoms of depression from their analyses and focusing solely on the
cognitive and affective components of depression (e.g., Peterson et
al., 1991; Smith, Christensen, Peck, & Ward, 1993). It appears,
however, that such an approach may unnecessarily sacrifice the
content validity of the instrument. Specifically, empirical research
suggests that the somatic items do not necessarily demonstrate
differential validity in patients with chronic medical illness (Aikens et al., 1999), and previous work with hemodialysis patients has
shown consistent results both with and without the inclusion of
somatic items in the BDI (Penley, Wiebe, Nwosu, & Raudales,
2000).
Our results provide the first data addressing the equivalence of
the Spanish BDI-II and the English BDI-II. Although the sample
size is quite small (23), it reveals valuable information. We found
that the bilingual participants Spanish and English BDI-II scores
were significantly correlated and that their Spanish and English
total scores were not significantly different from one another.
Together, the present results tentatively suggest that the Spanish
BDI-II is an appropriate translation and yields scores consistent
with those obtained from the English BDI-II. However, we again
emphasize that our analyses were based on a very small sample of
bilingual patients. Clearly, sample size is an issue and raises
questions of the stability of the findings; as such, it is necessary to
further explore item functioning in a larger sample of bilingual
individuals.
In terms of clinical significance, perhaps the most important
finding from the bilingual subsample is that patients are placed
into different depth of depression categories depending on which
translation of the BDI-II is referenced. Recall that approximately
30% of patients within the subsample were placed into different
depressive categories depending on whether their Spanish or English scores were used. Although most patients were placed into
more severe depressive categories on the basis of their English
BDI-II total scores, a few are placed into more severe depressive
categories on the basis of their Spanish BDI-II total scores. Interestingly, over half of the patients placed in different depressive
categories were placed into nonadjacent depressive categories.
Although the differential placement into depressive categories
might suggest that the Spanish and English BDI-IIs are not truly

575

equivalent, the very small subsample again precludes such definitive statements.
Because these are the first known data for the Spanish BDI-II,
it is important to gather additional information about the translation. Certainly, the small sample size and the very small bilingual
subsample raise questions about the generalizability and stability
of the results, particularly in terms of the overall model fit in the
population. Additional research is needed to address these issues
and to provide additional information about the Spanish BDI-II not
available in the present study (e.g., testretest reliability).
It is also important to continue exploration into the role of
culture and acculturation in depression (see Lopez & Guarnaccia,
2000). This exploration involves at least two main themes. First,
additional research is needed into cultural differences in the prevalence of depressive symptomatology. That is, some researchers
maintain that there is differential prevalence of depressive symptoms in Latino versus Anglo cultures (attributed to differences in
factors such as poverty and social support; Cuellar & Roberts,
1984; Golding & Burnam, 1990), whereas others maintain that
there are no cultural differences in prevalence rates (see Mirowsky
& Ross, 1984). Second, research is needed into cultural differences
in the reporting of depressive symptomatology. To address the two
issues, however, would require access to a variety of information
unavailable in the present research (e.g., in-depth participant interviews, contacts with social support networks).

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Received September 24, 2002

Revision received May 27, 2003
Accepted July 3, 2003